Protecting, Maintaining and Improving the Health of Minnesotans
Certified Mail # 7004 1160 0004 8714 3569
October 4, 2005
Christian Rivard, Administrator
Adult Help & Companion Care
4584 Cedar Lake Rd Suite 5
St. Louis Park, MN 55416
Re: Results of State Licensing Survey
Dear Mr. Rivard:
The above agency was surveyed on June 16, 17, 20 and 22, 2005 for the purpose of assessing compliance
with state licensing regulations. State licensing deficiencies, if found, are delineated on the attached
Minnesota Department of Health (MDH) correction order form. The correction order form should be
signed and returned to this office when all orders are corrected. We urge you to review these orders
carefully, item by item, and if you find that any of the orders are not in accordance with your
understanding at the time of the exit conference following the survey, you should immediately contact
me, or the RN Program Coordinator. If further clarification is necessary, I can arrange for an informal
conference at which time your questions relating to the order(s) can be discussed.
A final version of the Licensing Survey Form is enclosed. This document will be posted on the MDH
website.
Also attached is an optional Provider questionnaire, which is a self-mailer, which affords the provider
with an opportunity to give feedback on the survey experience.
Please feel free to call our office with any questions at (651) 215-8703.
Sincerely,
Jean Johnston, Program Manager
Case Mix Review Program
Enclosures
cc:
Christian Rivard, President Governing Body
Kelly Crawford, Minnesota Department of Human Services
Hennepin County Social Services
Sherilyn Moe, Office of the Ombudsman
CMR File
CMR 3199 6/04
Class A Licensed-Only Survey Report Form
Page 1 of 16
Class A Licensed-Only Home Care Provider
LICENSING SURVEY FORM
Registered nurses from the Minnesota Department of Health (MDH) use this Licensing Survey
Form during on-site visits to evaluate the care provided by Class A Licensed-Only Home Care
Providers. Class A licensees may also use this form to monitor the quality of services provided
to clients at any time. Licensees may use their completed Licensing Survey Form to help
communicate with MDH nurses during an on-site regulatory visit.
During on-site visit/s, MDH nurses will interview staff, talk with clients and/or their
representatives and make observations during home visits, and review documentation. The
survey is an opportunity for the licensee to explain to the MDH nurse what systems are in place
to provide Class A Licensed-Only Home Care services. Completing this Licensing Survey Form
in advance would facilitate the survey process.
Licensing requirements listed below are reviewed during a survey. A determination is made
whether the requirements are met or not met for each Indicator of Compliance. This form must
be used in conjunction with a copy of the Class A Licensed-Only Home Care regulations. Any
violations of the Class A licensing requirements are noted at the end of the survey form. [This
form is NOT intended to be used for Class A Licensees who are also certified to participate
in the Medicare program].
Name of Class A Licensee: ADULT HELP & COMPANION CARE
HFID # (MDH internal use): 03855
Date(s) of Survey: June 16, 17, 20 and 22, 2005
Project # (MDH internal use): QL03855008
Indicators of Compliance
1. The Provider accepts and
retains clients for whom it can
meet the needs.
•
•
•
•
•
•
MN Rules 4668.0050
MN Rule 4668.0060
Subpart 3
MN Rule 4668.0060
Subpart 4
MN Rule 4668.0060
Subpart 5
MN Rule 4668.0140
MN Rule 4668.0180
Subpart 8
2. The Provider promotes client
rights.
•
•
MN Statute §144A.44
MN Rule 4668.0030
Outcomes Observed
•
•
•
•
•
•
Clients are accepted based on the
availability of staff, sufficient in
qualifications and numbers, to
adequately provide the services
agreed to in the service
agreement.
Service plans accurately describe
the needs and services and
contains all the required
information.
Services agreed to are provided
Clients are provided referral
assistance.
Comments
Annual Licensing Survey
Met
Correction
X
Order(s) issued
Education
X
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Clients’ are aware of and have their Annual Licensing Survey
Met
rights honored.
Correction
X
Clients’ are informed of and
Order(s)
issued
afforded the right to file a
Education
X
complaint.
Class A Licensed-Only Survey Report Form
Indicators of Compliance
Outcomes Observed
• MN Rule 4668.0040
Indicator of Compliance #2
continued:
•
MN Rule 4668.0170
3. The Provider promotes and
protects each client’s safety,
property, and well-being.
•
•
•
•
•
•
•
MN Rule 4668.0035
MN Statutes §144A.46
Subdivision 5
MN Statute §626.556
MN Statutes §626.557
MN Statute §626.5572
•
•
•
Client’s person, finances and
property are safe and secure.
All criminal background checks
are performed as required.
Clients are free from
maltreatment.
There is a system for reporting
and investigating any incidents of
maltreatment.
Maltreatment assessments and
prevention plans are accurate and
current.
.
4. The Provider maintains and
protects client records.
•
MN Rule 4668.0160
•
Client records are maintained
and retained securely.
•
Client records contain all
required documentation.
•
Client information is released
only to appropriate parties.
Discharge summaries are
available upon request.
•
[Note to MDH staff: See
Informational Bulletin 99-11
for Class A variance for
Electronically Transmitted
Orders]
5. The Provider employs and/or
contracts with qualified and
trained staff.
•
•
•
MN Rule 4668.0060
subpart 1
• MN Rule 4668.0065
• MN Rule 4668.0070
• MN Rule 4668.0075
• MN Rule 4668.0080
• MN Rule 4668.0100
[For subpart 2 see indicator #6]
Indicator of Compliance #5
•
•
•
•
Staff, employed or contracted,
have received all the required
training.
Staff, employed or contracted,
meet the Tuberculosis and all
other infection control guidelines.
Personnel records are maintained
and retained.
Licensee and all staff have
received the required Orientation
to Home Care.
Staff, employed or contracted, are
registered and licensed as required
by law.
Documentation of medication
Page 2 of 16
Comments
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Annual Licensing Survey
Met
Correction
X
Order(s) issued
Education
X
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Annual Licensing Survey
Met
Correction
X
Order(s) issued
Education
X
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Annual Licensing Survey
Met
Correction
X
Order(s) issued
Education
X
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Class A Licensed-Only Survey Report Form
Indicators of Compliance
Outcomes Observed
continued:
•
•
•
•
MN Rule 4668.0120
MN Rule 4668.0130
MN Statute 144A.45
Subdivision 5
MN Statute 144A.461
[Note to MDH staff: See
Informational Bulletin 99-7 for
Class A variance in a Housing
With Services setting]
6. The Provider obtains and
keeps current all medication and
treatment orders [if applicable].
•
•
MN Rule 4668.0150
MN Rule 4668.0100
[Subpart 2]
•
•
•
•
•
•
[Note to MDH staff: See
Informational Bulletin 99-7 and
04-12 for Class A variance in a
Housing With Services setting
with regards to medication
administration, storage and
disposition.]
7. The Provider is licensed and
provides services in accordance
with the license.
•
•
•
•
•
•
•
•
MN Rule 4668.0008
subpart 3
MN Rule 4668.0012
subpart 8
MN Rule 4668.0012
Subpart 17
MN Rule 4668.0019
MN Rule 4668.0060
subpart 2
MN Rule 4668.0060
subpart 6
MN Rule 4668.0180
subpart 2
MN Rule 4668.0180
subpart 3
Indicator of Compliance #7
continued:
•
•
•
•
•
Page 3 of 16
Comments
administration procedures are
available.
Supervision is provided as
required.
Medications and treatments
administered are ordered by a
prescriber.
Medications are properly labeled.
Medications and treatments are
administered as prescribed.
Medications and treatments
administered are documented.
Medications and treatments are
renewed at least every three
months.
Annual Licensing Survey
Not Applicable
Met
Correction
X
Order(s) issued
Education
X
Provided
Language requiring compliance
with Home Care statutes and rules
is included in contracts for
contracted services.
License is obtained, displayed,
and renewed.
Licensee’s advertisements
accurately reflects services
available.
Licensee provides services within
the scope of the license.
Licensee has a contact person
available when a paraprofessional is working.
Annual Licensing Survey
Met
Correction
X
Order(s) issued
Education
X
Provided
Follow-up Survey #______
Not Applicable
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Follow-up Survey #______
Met
Not Met
New Correction
Order(s) issued
Education
Provided
Class A Licensed-Only Survey Report Form
Indicators of Compliance
•
•
•
•
•
•
Page 4 of 16
Outcomes Observed
Comments
MN Rule 4668.0180
subpart 4
MN Rule 4668.0180
subpart 5
MN Rule 4668.0180
subpart 6
MN Rule 4668.0180
subpart 7
MN Rule 4668.0180
subpart 9
MN Statute 144A.47
[Note to MDH staff: Review 17
point contract if services
provided in a Housing With
Services]
Please note: Although the focus of the licensing survey is the regulations listed in the
Indicators of Compliance boxes above, other violations may be cited depending on what
systems a provider has or fails to have in place and/or the severity of a violation. Also, the
results of the focused licensing survey may result in an expanded survey where additional
interviews, observations, and documentation reviews are conducted.
SURVEY RESULTS:
For Indicators of Compliance not met and/or education provided, list the number, regulation
number, and example(s) of deficient practice noted:
Correction
Order
Number
Indicator of
Compliance
Number
1
2
Rule/ Statute
Referenced
MN Rule
4668.0040 Subp. 1
Complaint procedure
Education
provided
Statement(s) of Deficient Practice/Education:
X
Based on record review and interview,
the licensee failed to establish in writing
a system for receiving, investigating and
resolving complaints for three of three
clients (#1, #2 and #3) reviewed. The
findings include:
Client #1 was admitted September 1,
2004, client #2 was admitted June 01,
2002, and client # 3 was admitted on
December 1, 2003. During a review of
these clients’ records there was no
evidence of the client or family
receiving a written complaint procedure.
During interview on June 17, 2005 the
owner stated he was not aware of the
need to have a separate complaint
procedure. The owner indicated that he
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 5 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
thought the information on the Home
Care Bill of Rights was adequate.
Education: Provided
2
5
MN Rule
4668.0065 Subp. 1
Tuberculosis screening
X
Based on record review and interview,
the licensee failed to ensure that all
employees had a screening for
tuberculosis before having direct contact
with clients for five of five employees
(#1, #2, #3, #4 and #5) reviewed. The
findings include:
Employee #1 was hired August 2001,
employee #2 started the business in
February 2001, employee #3 was hired
May 2001, employee #4 was hired June
2002 and employee #5 was hired May
12, 2005. There was no evidence that
tuberculin testing had been completed
for any of the above-mentioned
employees. When interviewed on June
17, 2005 the owner verified that
tuberculosis screening had not been
completed for him or any of the
employees mentioned above, prior to
direct contact with clients. The owner
verified that he performed home health
aide tasks in the clients’ homes when
other home health aides were unable to
work.
Education: Provided
3
5
MN Rule
4668.0065 Subp. 3
Infection control inservice training
X
Based on record review and interview,
the licensee failed to ensure that for
each twelve months of employment,
employees who have contact with
clients completed training about
infection control techniques used in the
home for five of five (#1, #2, #3, #4 and
#5) employees reviewed. The findings
include:
Employee #1 was hired August 2001,
employee #2 started the business in
February 2001, employee #3 was hired
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 6 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
May 2001, employee #4 was hired June
2002 and employee #5 was hired May
12, 2005. There was no evidence that
infection control in-services had been
completed. When interviewed on June
17, 2005, the owner verified that
infection control in-services had not
been completed within the past 12
months for him, or any of the employees
reviewed who had direct client contact.
Education: Provided
4
5
MN Rule
4668.0070 Subp. 2
Personnel records
X
Based on record review and interview,
the licensee failed to maintain a record
for five of five (#1, #2, #3, #4 and #5)
employees reviewed. The findings
include:
Employee #1 was hired August 2001,
employee #2 started the business in
February 2001, employee #3 was hired
May 2001, employee #4 was hired June
2002 and employee #5 was hired May
12, 2005. During review of records
there were no individual employee files
for the above-mentioned employees.
When interviewed on June 17, 2005, the
owner verified that he did not keep a
separate file for each employee.
Education: Provided
5
5
MN Rule
4668.0070 Subp. 3
Job descriptions
X
Based on record review and interview,
the licensee failed to maintain a current
job description, including qualifications,
responsibilities, and identification of
supervisors for five of five (#1, #2, #3,
#4 and #5) employees reviewed. The
findings include:
Employee #1, a licensed practical nurse
was hired August 2001, employee #2,
owner/home health aide started the
business in February 2001, employee
#3, a registered nurse was hired May
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 7 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
2001, employee #4, a home health aide
was hired June 2002 and employee #5, a
home health aide was hired May 12,
2005. There were no individual
employee job descriptions for any of the
above-mentioned employees. When
interviewed on June 17, 2005, the owner
verified that he did not have job
descriptions for the different positions.
Education: Provided
6
5
MN Rule
4668.0075 Subp. 1
Orientation
X
Based on record review and interview,
the licensee failed to ensure that two of
five employees (#4 and #5) who
provided direct care to clients completed
an orientation to the home care
requirements. The findings include:
Employee #4 was hired on June 2002
and employee #5 was hired on May 12,
2005 to provide direct care to clients.
There was no evidence that employees
#4 and #5 had completed an orientation
to home care requirements. When
interviewed on June 17, 2005, the owner
verified that employees #4 and #5 had
not completed an orientation to the
home care requirements as required.
Education: Provided
7
5
MN Rule
4668.0075 Subp. 4
Verification and
documentation
X
Based on record review and interview,
the licensee failed to ensure
documentation of orientation to the
home care requirements was retained for
three of three employees (#1, #2, #3)
reviewed. The findings include:
Employee #1 was hired August 2001,
employee #2 started the business in
February 2001, and employee #3 was
hired May 2001. There was no evidence
that they had completed an orientation
to the home care requirements prior to
providing direct care. When
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 8 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
interviewed on June 17, 2005, the owner
stated that he had orientation to home
care by reading the Guide to Home Care
and that two of his nurses, employees #1
and #3 had worked for other home care
agencies and likely had completed an
orientation to home care at these
agencies. The owner was unable to
produce documentation to verify this
training.
Education: Provided
8
5
MN Rule
4668.0100 Subp. 2
Administration of
medications
X
Based on record review and interview,
the licensee failed to ensure that each
home health aide who administered
medications had been instructed by a
registered nurse in the procedure for
medication administration prior to
administering medications; failed to
ensure there was a procedure written by
a registered nurse for each medication
being administered by a home health
aide; and did not have evidence of home
health aide competency evaluation for
following the client specific written
procedures for three of three (#2, #4,
and #5) home health aides who
administered medications to clients.
The findings include:
The records for clients #1, #2 and #3
indicated that the home health aides
were administering medications.
Employee #2 started the business in
February 2001 and stated that he
provided cares when employees were
unable to work; employee #4 was hired
June 2002 and provided cares including
medication administration to client #2;
and employee #5 was hired May 12,
2005 and provided cares including
medication administration to client #1.
There was no evidence that the home
health aides were instructed by the
registered nurse on medication
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 9 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
administration. There was a procedure,
written by the licensed practical nurse,
for medication administration in the
record for client #1 and a procedure,
written by the owner, a home health
aide, for medication administration, in
the records for clients #2 and #3. There
was no evidence of competency
evaluations for medication
administration for employees #2, #4,
and #5. During an interview with the
owner on June 17, 2005, he confirmed
that the medication administration
procedures had not been written by a
registered nurse nor was there a
demonstration of competency to the
registered nurse of the home health
aides’ ability to perform medication
administration.
Education: Provided
9
5
MN Rule
4668.0100 Subp. 5
Qualifications for
persons who perform
home health aide tasks
X
Based on record review and interview,
the licensee failed to ensure that three of
three (#2, #4 and #5) home health aides
were qualified to perform home health
aide tasks. The findings include:
Employees #2, #4, and #5 performed
home health aide tasks. There was no
evidence of training and competency
evaluations for these employees. During
interview on June 17, 2005 the owner
stated that employees #2, #4, and #5 had
not received the required training and
competency evaluation.
Education: Provided
10
5
MN Rule
4668.0100 Subp. 6
In-service training and
demonstration of
competence
X
Based on record review and interview,
the licensee failed to ensure that for
each twelve months of employment,
each person who performed home health
aide tasks completed at least eight hours
of inservice training in topics relevant to
the provision of home care services for
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 10 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
three of three (#2, #4, #5) home health
aides reviewed. The findings include:
Employee #1 was hired August 2001,
employee #2 started the business in
February 2001, employee #3 was hired
May 2001, employee #4 was hired June
2002 and employee #5 was hired May
12, 2005. There was no documentation
of eight hours of inservice training for
each 12 twelve months of employment
for the above-mentioned employees.
When interviewed on June 17, 2005 the
owner stated that he had no inservice
records for any of his employees or
himself.
Education: Provided
11
5
MN Rule
4668.0100 Subp. 9
Periodic supervision of
home health aide tasks
X
Based on record review and staff
interview the licensee failed to have a
registered nurse (RN) supervise home
health aides to assure work was being
performed adequately for three of three
(#1, #2 and #3) clients’ records
reviewed. The findings include:
Client #1 was admitted September 1,
2004, client #2 was admitted June 01,
2002, and client #3 was admitted on
December 1, 2003. During record
review there was no documentation in
any of the clients records that
established an initial 14 day supervisory
visit was made nor was there
documentation that the 60 day
supervisory visits were made. During
interview with the owner on June 17,
2005 he agreed that the registered nurse
was not making supervisory visits of the
home health aides. He stated that the
licensed practical nurse visited client #1
every two weeks and that the registered
nurse visited client #2 every week but
these visits were not supervisory visits
of the home health aides.
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 11 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
Education: Provided
12
5
MN Rule
4668.0130 Subp. 3
Competency evaluation
X
Based on record review and interview,
the licensee failed to have a registered
nurse administer competency evaluation
tests on three of three (#2, #4, #5)
employees providing home health aide
tasks.
Findings include:
Employee #2 started the business in
February 2001 and stated that he
provided cares when employees were
unable to work; employee #4 was hired
June 2002 and provided cares including
medication administration to client # 2;
and employee #5 was hired May 12,
2005 and provided cares including
medication administration to client #1.
During review of employee files it was
determined that competency evaluation
tests were not completed on any of the
employees reviewed. During interview
with owner on June 17, 2005 he verified
that there was no documentation of
competency evaluation tests.
Education: Provided
13
1
MN Rule
4668.0140 Subp. 1
Service agreements
X
Based on record review and interview,
the licensee failed to have written
service agreements for three of three
(#1, #2 and #3) clients’ records
reviewed. The findings include:
Client #1 was admitted September 1,
2004, client #2 was admitted June 01,
2002, and client # 3 was admitted on
December 1, 2003. A review of client
#1, #2, and #3s’ records did not include
service agreements. During interview
on June 17, 2005, the owner verified
that there were no written service
agreements for the above-mentioned
clients. During a home visit with client
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 12 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
#1, employee #1 stated that there was no
written service agreement kept at the
client’s home, but stated that she had
written a care plan that did not contain
all components of a service agreement
and was not signed by the client or their
representative. During a home visit with
client #2, employee #4 stated there was
no written service agreement at the
home indicating what services the client
was to receive.
Education: Provided
14
6
MN Rule
4668.0150 Subp. 6
Renewal of orders
X
Based on record review and interview,
the licensee failed to obtain a renewal of
physician orders at least every three
months for two of two (#1 and #3)
clients reviewed. Findings include:
During review of client #1’s record,
there were physician orders for
medications to be given dated
November 05, 2004, but no evidence of
renewal of these orders every three
months. Client record #2 had
physician’s orders for medications to be
given dated September 21, 2004. There
was no evidence of a renewal of these
orders every three months. During an
interview on June 17, 2005, the owner
stated that they usually tried to have
physician’s orders for medications and
treatments that agency staff were to
provide. The owner confirmed that they
had not been making sure to have
renewals by the physician every three
months.
Education: Provided
15
4
MN Rule
4668.0160 Subp. 1
Maintenance of client
record
X
Based on record review and interview,
the licensee failed to maintain a record
for each client for three of three (#1, #2,
#3) clients reviewed. The findings
include:
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 13 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
Client #1 was admitted September 1,
2004, client #2 was admitted June 01,
2002, and client # 3 was admitted on
December 1, 2003. During review of
these clients’ information, several
different file folders containing
documents for each client were noted.
Some of these folders were at the office
and others were in the clients’ home.
Additional records for client #1 and #2
were in the possession of the nurse.
Client #3, who had been discharged, had
documents pertaining to him, in with
another client’s information. During an
interview on June 17, 2005 the owner
stated he did not have one place where
the complete file for each client was
kept.
Education: Provided
16
4
MN Rule
4668.0160 Subp. 6
Content of client record
X
Based on record review and interview,
the licensee failed to maintain clients’
records containing name, address,
telephone number, date of birth, dates of
the beginning and end of services,
names addresses and telephone numbers
of any responsible persons, a service
agreement, medication and treatment
orders, if any, notes summarizing each
contact with the client, names addresses
and telephone numbers of the clients
medical providers, and a summary
following the termination of services.
The findings include:
Client #1 was admitted September 1,
2004, client #2 was admitted June 01,
2002, and client # 3 was admitted on
December 1, 2003. During review of
these clients’ records, we were unable to
locate a definitive date for the beginning
of service for any of these clients and on
the discharge record (#3) the exact
discharge date was not noted. There was
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 14 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
no evidence of a service plan in any of
these records, there were no notes
summarizing each visit to the client and
the discharge record did not have a
discharge summary. During interview
on June 17, 2005 the owner agreed that
he did not have an individualized client
record for each of these clients
containing the start of service dates, a
service agreement or notes summarizing
each client visit. He stated that there is a
sheet at each client’s home where the
home health aides are to initial by each
service provided each day. During home
visit to client #1 it was noted that the
sheets to document services provided
were rarely filled in by the home health
aides. The licensed practical nurse
interviewed at the home of client #1
verified that this was a problem to get
the home health aides to document
consistently. The owner also agreed
there was no discharge summary
documented for client #3.
Education: Provided
17
3
MN Statute
§144A.46 Subd. 5
Prior criminal
convictions
X
Based on record review and interview,
the licensee failed to conduct criminal
background studies for four of five (#1,
#3, #4 and #5) employees who had
direct client contact. The findings
include:
Employee #1 was hired August 2001,
employee #3 was hired May 2001,
employee #4 was hired June 2002 and
employee #5 was hired May 12, 2005.
There was no evidence of a required
criminal background study having been
completed for the above-mentioned
employees by the Department of Human
Services. During an interview with the
owner on June 17, 2005, he stated that
he had been using a private agency to do
his background checks and had thought
Class A Licensed-Only Survey Report Form
Correction
Order
Number
Indicator of
Compliance
Number
Rule/ Statute
Referenced
Page 15 of 16
Education
provided
Statement(s) of Deficient Practice/Education:
that was acceptable.
Education: Provided
18
3
MN Statute
§626.557 Subd. 14 (b)
Abuse prevention plans
X
Based on record review and
interview, the licensee failed to develop
an individual abuse prevention plan for
three of three (#1, #2 and #3) vulnerable
adults receiving services. The findings
include:
Client #1 was admitted June 9,
2004, client #2 was admitted June 01,
2002 and client # 3 was admitted on
December 1, 2003. A review of client
records indicated that client #3 had a
vulnerable adult assessment done by a
registered nurse on September 24, 2004
but there was no specific measures
documented that were to be taken to
minimize the risk of abuse to this client.
There was no assessment of clients #1
and #3’s susceptibility to abuse by
others noted in their records. When
interviewed on June 17, 2005 the owner
agreed that there were no vulnerable
adult assessments for clients #1 and #2
and that he did not have written abuse
prevention plans in place.
Education: Provided
2
4
7
MN Statute
§144A.44 Subd. 1
Home Care Bill of
Rights
X
MN Rule
4668.0160 Subp. 2
Security of client
records
X
MN Rule
4668.0012 Subp. 17
Display of license
X
Education: Provided
Education: Provided
Education: Provided
Class A Licensed-Only Survey Report Form
Page 16 of 16
A draft copy of this completed form was left with Christian Rivard at an exit conference on June
22, 2005. Any correction orders issued as a result of the on-site visit and the final Licensing
Survey Form will arrive by certified mail to the licensee within 3 weeks of this exit conference
(see Correction Order form HE-01239-03). If you have any questions about the Licensing
Survey Form or the survey results, please contact the Minnesota Department of Health, (651)
215-8703. After supervisory review, this form will be posted on the MDH website. General
information about CLASS A Licensed-Only Home Care Provider is also available on the MDH
website:
http://www.health.state.mn.us
Regulations can be viewed on the Internet: http://www.revisor.leg.state.mn.us
(Form Revision 5/05)